IngentaConnect Non-invasive diagnostic work-up of patients with clinically suspe...

Authors: Ten Wolde M.; Hagen P.J.¹; Macgillavry M.R.²; Pollen I.J.; Mairuhu A.T.A.²; Koopman M.M.W.; Prins M.H.³; Hoekstra O.S.⁴; Brandjes D.P.M.²; Postmus P.E.¹; Büller H.R.

Source: Journal of Thrombosis and Haemostasis, Volume 2, Number 7, July 2004 , pp. 1110-1117(8)

Publisher: Blackwell Publishing

Abstract:

Summary. Background

: Clinicians often deviate from the recommended algorithm for the diagnosis of pulmonary embolism consisting of ventilation-perfusion scintigraphy and pulmonary angiography. Objectives

: To assess the safety and feasibility of a diagnostic algorithm which reduces the need for lung scintigraphy and avoids the use of angiography. Patients and methods

: Consecutive patients with a clinical suspicion of pulmonary embolism were prospectively investigated according to an algorithm in which the diagnosis of pulmonary embolism was excluded after a low clinical probability estimate and a normald-dimer test result, a normal perfusion scintigraphy result, or a non-high probability scintigraphy result in combination with normal serial ultrasonography of the legs. In these patients anticoagulant treatment was withheld and they were followed up for 3 months to record possible thromboembolic events. During the study period, 923 consecutive patients were seen, of whom 292 were excluded because of predefined criteria. Results

: Of the 631 included patients, the diagnosis was refuted on the basis of a low clinical probability estimate and a normald-dimer test result (95 patients), normal perfusion scintigraphy (161 patients) and non-high probability lung scintigraphy followed by normal serial ultrasonography (210 patients). Of these 466 patients, venous thromboembolic complications during follow-up occurred in six (complication rate 1.3%, 95% confidence interval 0.5, 2.8). The diagnostic protocol was completed in 92% of all included patients. Conclusion

: The diagnosis of pulmonary embolism can be safely ruled out by a non-invasive algorithm consisting ofd-dimer testing combined with a clinical probability estimate, lung scintigraphy, or serial ultrasonography of the legs (in case of non-diagnostic lung scintigraphy).

Keywords: d-dimer; diagnosis; pulmonary embolism; serial ultrasonography

Document Type: Research article

DOI: 10.1111/j.1538-7836.2004.00769.x

Affiliations: 1: Department of Pulmonary Medicine, Vrije Universiteit Medical Center 2: Department of Internal Medicine, Slotervaart Hospital, Amsterdam, the Netherlands 3: Department of Clinical Epidemiology and Medical Technology Assessment, Academic Hospital Maastricht, Maastricht, the Netherlands 4: Department of Nuclear Medicine, Vrije Universiteit Medical Center, Amsterdam, the Netherlands

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Non-invasive diagnostic work-up of patients with clinically suspected pulmonary embolism; results of a management study